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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Rupi Padda CHECK if BILLING ADDRESS <br /> FACILITY NAME Plaza Liquors <br /> SITE ADDRESS 2420 W Turner Rd Lodi 95242 <br /> Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOC 0 CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX# <br /> (209 ) 461-6342 <br /> CITY Stockton STATE Ca Zip 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 949-r.IL i�` DATRtE::tt 10/15/2018 <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El Office Assistant <br /> IfAPPL1CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> inforllation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the samPA <br /> provided to me or Imy representative. _ �1 ry�Jc'Nl. <br /> TYPE OF SERVICE REQUESTED: �D <br /> COMMENTS: <br /> �5 <br /> 7018 <br /> Qlilj-x f tl14� jfjq�RONMF UN)y <br /> M DEp Al <br /> NT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> tv 1 t <br /> ASSIGNED TO: S Gr EMPLOYEE M ��nn DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� P I E:IT <br /> ' }� l <br /> Fee Amount: Amount Paid—,.APayment Date <br /> Payment Type I1 — Invoice# Ch k# g3���6� Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />